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\begin{document}

\title{Outpatient management of epistaxis during COVID-19 to reduce inpatient
stay: a quality improvement project}



\author[1]{Kaso Ari}%
\author[1]{Rachael Collins}%
\affil[1]{Norfolk and Norwich University Hospital}%


\vspace{-1em}



  
  \date{May 20, 2024}


\begingroup
\let\center\flushleft
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\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Introduction: In March 2020, new guidelines allowed patients with
epistaxis to be discharged home with nasal packs in situ to reduce the
risk of inpatient covid transmission rates. Our objective is to review
how successful these new guidelines have been and whether they could be
safely maintained in future practice. Methods: This was a retrospective
data analysis at a local tertiary ENT referral hospital. The study group
consisted of patients admitted with epistaxis over one year. The ``Pack
and Home'' criteria pathway was implemented. We reviewed the pathway 6
months pre and 6 months post pathway introduction. Primary outcome
measure included compliance with the ``Pack and Home'' criteria and
length of inpatient admissions. Results: A total of 131 patients
required nasal packing, with 72 patients (55\%) in loop 1 and 59
patients (45\%) in loop 2. In the first loop all 72 patients (100\%)
were admitted for inpatient care. However, in the second loop 21
patients (36\%) were discharged home with nasal pack in situ and 59
patients (64\%) were admitted. Of those discharged, 2 patients
re-presented after 48 hours with re-bleeding. The average total length
of inpatient stay in loop 1 was significantly higher at 45.7 hours and
29.6 hours in loop 2 (p\textless{}0.05). All discharged patients
attended their outpatient appointment in under 3 days. Conclusion The
``Pack and Home'' criteria can successfully identify patients who are
suited for an outpatient management pathway. This could reduce surgical
inpatient load and the way we manage epistaxis.%
\end{abstract}%



\sloppy


\textbf{Abstract}

\textbf{Introduction} :

In March 2020, new guidelines allowed patients with epistaxis to be
discharged home with nasal packs in situ to reduce the risk of inpatient
covid transmission rates. Our objective is to review how successful
these new guidelines have been and whether they could be safely
maintained in future practice.

\textbf{Methods} :

This was a retrospective data analysis at a local tertiary ENT referral
hospital. The study group consisted of patients admitted with epistaxis
over one year. The ``Pack and Home'' criteria pathway was implemented.
We reviewed the pathway 6 months pre and 6 months post pathway
introduction. Primary outcome measure included compliance with the
``Pack and Home'' criteria and length of inpatient admissions.

\textbf{Results} :

A total of 131 patients required nasal packing, with 72 patients (55\%)
in loop 1 and 59 patients (45\%) in loop 2. In the first loop all 72
patients (100\%) were admitted for inpatient care. However, in the
second loop 21 patients (36\%) were discharged home with nasal pack in
situ and 59 patients (64\%) were admitted. Of those discharged, 2
patients re-presented after 48 hours with re-bleeding. The average total
length of inpatient stay in loop 1 was significantly higher at 45.7
hours and 29.6 hours in loop 2 (p\textless{}0.05). All discharged
patients attended their outpatient appointment in under 3 days.

\textbf{Conclusion}

The ''Pack and Home'' criteria can successfully identify patients who
are suited for an outpatient management pathway. This could reduce
surgical inpatient load and the way we manage epistaxis.

Five key points

\begin{itemize}
\tightlist
\item
  The ``Pack and Home'' criteria was developed by our local hospital
  trust to manage epistaxis on an outpatient basis
\item
  Prior to the pandemic all epistaxis cases were admitted as inpatients,
  whereas the newly implemented criteria resulted in the avoidance of 21
  admissions over 6 months
\item
  Only two patients on the ``Pack and Home'' pathway re-presented with
  bleeding within 48 hours.
\item
  The new criteria lead to an overall reduction in length of hospital
  stay for patients presenting with epistaxis
\item
  We recommend continuing outpatient management pathway of epistaxis
  under the circumstances that clinicians are fully aware of which
  patients meet the criteria, patients are counselled appropriately and
  to be see in clinic within 48 hours of discharge
\end{itemize}

\textbf{Introduction}

Epistaxis is a common presentation to Ear, Nose and Throat (ENT)
departments across the UK with the majority of requiring hospital
admission despite most patients requiring no further intervention other
than simple nasal packing\textsuperscript{1,2}. Due to its involvement
with the upper respiratory tract and being described as an aerosol
generating procedure, the management of epistaxis posed an increased
risk of the spread of Sars-CoV-2 to staff and
patients\textsuperscript{3}. In March 2020, new guidelines were altered
to enable certain patients to be discharged home with nasal packs in
situ to reduce the risk of COVID-19 inpatient
transmission\textsuperscript{4}. The literature has highlighted the
implications around safe discharge, reduced hospital stay and
re-admission rates for patients with epistaxis\textsuperscript{5,6}.

A criterion was created to help identify patients that would be suitable
for outpatient management. This included their social circumstances,
stability of patients, observation parameters and past medical history.
Correct adherence to the new guideline could lead to reduced admission
of epistaxis patients and occupancy of beds within the
hospital\textsuperscript{7}.

\par\null

\textbf{Objectives:}

The objective of this audit is to review how successful the new ``Pack
and Home'' Criteria has been during the COVID-19 pandemic and whether
they could be safely maintained in future practice use.

\textbf{Methods}

This manuscript has been prepared with reference to the STROBE checklist
for cohort studies

\textbf{Ethical consideration}

The project was reviewed, approved, and registered by the trust's audit
department. The Health Research Authority decision tool determined the
study design to fall under the remit of audit, and so no ethical
approval was required.

\textbf{Study design and setting}

This was a retrospective data analysis of pre and post implementation of
the new guidelines which were introduced in March 2020. The ``Acute
Epistaxis COVID guideline'' (Appendix 1) with ``Pack and Home Criteria''
(Appendix 2) were distributed amongst A\&E staff and ENT clinicians
within the hospital by electronic and paper forms. Firstly, we reviewed
the pathway prior to the new guidelines over 6 months (Loop 1 -
September 2019 to March 2020) and then reviewed 6 months post the new
guidelines (Loop 2 - March 2020 to Sept 2020).

\textbf{Participants}

The study group consisted of all patients, aged 18 years and older,
admitted to A\&E with epistaxis requiring nasal packing as a form of
management during September 2019 to September 2020.

\textbf{Data analysis}

Primary outcome measure included:

Compliance to ``Pack and Home'' Criteria

Length of inpatient admission

Secondary outcome measures included:

\begin{itemize}
\tightlist
\item
  Re-bleeding post pack removal
\item
  Re-presentation with bleeding within 48 hours
\item
  Re-presentation within 1 month
\end{itemize}

A descriptive analysis was performed of the baseline clinical
characteristics between patients studied in loop one and loop one of the
audit. Percentages were used for the categorical variables whilst mean
and standard deviations for the continuous variables. The t-test was
used to investigate for associations between continuous variables,
whereas chi-squared test of association was used for categorical
variables. Non-parametric testing (Mann Whitney U test) had been used
for length stay. The level of statistical significance was set at p
\textless{}0.05 and confidence intervals were reported at the 95\%
level. SPSS version 28 was used for statistical analysis.

The terms ``Pack and Home'' criteria and ``outpatient management
pathway'' are used synonymously in this paper. Patients that were deemed
not to be successfully managed on the outpatient pathway were those that
did met the criteria for the ``Pack and Home'' pathway or re-presented
with bleeding within 48 hours of discharge.

\textbf{Results}

414 patients presented to A\&E with epistaxis in the first loop and 309
patients in the second, of which 72 (17.4\%) and 59 (19.1\%) patients
required nasal packing respectively. This made up the final study
population, their clinical characteristics being demonstrated in table
1. No significance in difference (p\textgreater{}0.05) were demonstrated
between age, sex, and nasal pack types. However patients in loop one
were more likely to be on an anticoagulants including DOACS (direct oral
anticoagulants), warfarin and antiplatelets. Patients in loop one were
more likely to have a past medical history of Atrial Fibrillation (AF)
whereas no difference was demonstrated in the prevalence of other
comorbidities between the two groups.

Table 2 shows the outcome measures for patients in loop one and loop two
of the audit study. 59 patients required nasal packing in loop two of
the audit of which 38 patients (64.4\%) received inpatient care whereas
21 patients (35.6\%) had outpatient care, thus outlining those that had
met the ``Pack and Home'' criteria. In loop two of the audit study, 56
patients (94.9\%) were successfully discharged while 3 patients (5.1\%)
represented within 48 hours. These 3 patients were all on the ``Pack and
Home'' pathway. All patients discharged with a nasal pack were reviewed
in outpatient clinic in under 3 days with nearly
1/3\textsuperscript{rd}seen within 24 hours of pack removal and
consideration for nasal cautery. No difference was demonstrated for
those who had represented with epistaxis within 1 month between the two
study cohorts. Image 3 demonstrates the average total length of
inpatient stay in loop one to be significantly higher at 45.7 hours
whereas only 29.6 hours in loop two (p\textless{}0.05).

\textbf{Presentations unsuccessfully sent home with packs}

Image 2 demonstrates 3 patients on the ``Pack and Home'' criteria to
have re-presented within 48 hours of discharge therefore was
unsuccessfully sent home with nasal packing. One patient had a
background of ischaemic heart disease and valve replacement requiring
anticoagulation. One patient had no comorbidities whereas the other had
a history of prostate cancer. Two of the patients that returned with
bleeding receiving nasal packing with Merocel\selectlanguage{ngerman}®, whereas the third
patient returned to hospital complaining of pain from the nasal packing
but no bleeding.

\textbf{Re-bleeding post pack removal}

Image 2 also shows 5 patients in loop one to have re-bled post pack
removal. Of these, 3 immediately bled, one re-presented at 12 hours and
one represented at 24 hours. 3 of these patients had comorbidities
including hypertension and were on anticoagulants. 1 patient had nasal
polyps and the other was fit and well. In loop two, 7 patients had
re-bled of which 3 were on the outpatient pathway and 4 on the inpatient
pathway. 2 on the outpatient pathway had no significant comorbidities, 1
had ischaemic heart disease with valve replacement and therefore did not
meet the ``Pack and Home'' criteria. 4 inpatient re-bleeders had a
history of hypertension or were on anticoagulants.

\textbf{Re-presentation within month}

No significant difference was demonstrated for this outcome measure
between loop one and loop two patients (p\textgreater{}0.05). In loop
one, 11 patients all had comorbidities including hypertension and/or
taking anticoagulants. In loop two, 5 patients were healthy whereas 4
had hypertension and/or were taking anticoagulants.

\textbf{Discussion}

This audit investigated the compliance rate and safety implications of
the new ``Pack and Home'' criteria guidelines implemented during the
COVID-19 pandemic for patients with epistaxis requiring nasal packing.
Prior to the pandemic all those with epistaxis were admitted as
inpatients, whereas following the introduction of the new guidelines
approximately 1/3\textsuperscript{rd}with nasal packs in situ met the
criteria and did not require inpatient admission. The new ``Pack and
Home'' criteria resulted in the avoidance of 21 admissions over 6
months, therefore demonstrating an adequate compliance rate with the new
guidelines. 3 patients on the new pathway re-presented within 48 hours,
of which in retrospect one did not meet the criteria and should not have
been put on the outpatient pathway whereas one re-presented with pain
and the other with bleeding. Thus, with regards to safety implications,
only one patient on the ``Pack and Home'' pathway re-presented with
bleeding within 48 hours.

The INTEGRATE audit study (1) was able to show that patients can be
safely discharged with epistaxis and managed on an outpatient basis.
Avoidance of admission has implications towards reduced bed occupancy on
surgical wards and reduced opportunities for transmission of hospital
acquired infections. Like our study, the INTEGRATE paper demonstrated
not being packed in the emergency department and being on antiplatelet
medications were significant predictors of re-presentation within 10
days. Our study mainly demonstrated an association between being on an
anticoagulant and having certain co-morbidities, such as AF, with
epistaxis and potential re-bleed rates. Therefore, these are factors
that can impact the chances of successfully managing epistaxis on an
outpatient bases, according to the ``Pack and Home'' criteria.

Our study also revealed a reduced length of inpatient stay in the second
loop of the audit compared to the first (p \textless{}0.05). Reduced
length of stay within the hospital may have positive financial
implications. This was demonstrated in a study by McCrossan et al. (8),
looking at safely discharging patients home with rapid rhinos in situ,
where according to ``NICE costings statement'' there had been a drop in
cost/bed-day expenses by approximately £11000 due to reduced length of
inpatient stay. Therefore, the ``Pack and Home'' criteria may influence
financial constraints with regards to the possibility of increasing bed
availability on surgical wards.

Strengths of this audit study include the large study cohort analysed
during a pandemic under difficult circumstances. A key limitation of
this audit is the lack of generalisability of the results. Our study
population consists mainly of an elderly population which can impact the
risk of re-bleeding\textsuperscript{9} and raise safety concerns with
regards to appropriate outpatient management. A univariate analysis was
not performed in this study therefore we were unable to adjust of
potential confounding, despite their being minimal difference in
baseline characteristics between the first and second loop cohorts.

In summary, our audit study demonstrates the possibility of safely
discharging patients home with epistaxis, requiring nasal packs in situ,
and being managed on an outpatient pathway. Consideration must be taken
towards clinical characteristics of patients that meet the ``Pack and
Home'' criteria to ensure successful and safe compliance with the
pathway.

\textbf{Conclusion and Recommendations}

The `Pack and Home' criteria successfully identifies patients who are
suited to outpatient management pathway. Three patients on the `Pack and
Home' pathway re-presented back to hospital within 48 hours of which
only one re-bled and therefore deemed as unsuccessful management. This
pathway could reduce inpatient admissions, have positive financial
implications, and ultimately impact bed availability for surgical
patients.

Therefore we recommend the following:

\begin{itemize}
\tightlist
\item
  Ensure clinicians are fully aware of `pack and home' criteria.
\item
  Continue outpatient management pathway as routine (in non-pandemic
  times).
\item
  Patients should ideally be seen either the following day or day two of
  pack insertion (day 3+ not optimal).
\item
  We should ensure patients on the outpatient pathway are adequately
  counselled about what to do if re-bleed occurs and safety net.
\end{itemize}

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Epistaxis 2016: national audit of management. The Journal of
  Laryngology \&amp; Otology. 2017;131(12):1131-1141.
\item
  Upile T, Jerjes W, Sipaul F, El Maaytah M, Nouraei S, Singh S et al.
  The role of surgical audit in improving patient management; nasal
  haemorrhage: an audit study. BMC Surgery. 2007;7(1).
\item
  Clinical Recommendations for Epistaxis Management During the COVID-19
  Pandemic Vittorio D'Aguanno, MD*, Massimo Ralli, MD, PhD*, Antonio
  Greco, MD, Marco de Vincentiis, MD. Otolaryngology--Head and Neck
  Surgery. Vol 163, Issue 1, 2020
\item
  UpToDate {[}Internet{]}. Uptodate.com. 2022 {[}cited 7 August 2022{]}.
  Available from:
  https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis
\item
  Hardman J, Smith M, Swords C, Rocke J, Walker A, Bryan J et al.
  Admission avoidance in acute epistaxis: A prospective national audit
  during the initial peak of the COVID\selectlanguage{english}-19 pandemic. Clinical
  Otolaryngology. 2021;46(3):577-586.
\item
  Van Wyk F, Massey S, Worley G, Brady S. Do all epistaxis patients with
  a nasal pack need admission? A retrospective study of 116 patients
  managed in accident and emergency according to a peer reviewed
  protocol. The Journal of Laryngology \&amp; Otology.
  2006;121(3):222-227.
\item
  Tunkel D, Anne S, Payne S, Ishman S, Rosenfeld R, Abramson P et al.
  Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary.
  Otolaryngology--Head and Neck Surgery. 2020;162(1):8-25.
\item
  McCrossan S, O'Doherty K, Adair R. Epistaxis Management during the
  COVID-10 pandemic first wave -- Do we need to admit patients with
  rapid rhinos? A complete loop audit. British Journal of Surgery 108:
  6, 2021
\item
  Abrich V, Brozek A, Boyle T, Chyou P, Yale S. Risk factors for
  Recurrent Spontaneous Epistaxis. Mayo Clinic Proceedings 89(12): 1636
  -- 1643, 2014
\end{enumerate}

\textbf{Tables}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Demographic\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Loop 1\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Loop 2\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Total\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
p-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
No. A\&E Epistaxis Packed n (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
414 72 (17.4\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
309 59 (19.1)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
723 131\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
n/a\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Mean Age +/- SD Range\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
75.6 (+/- 16.1) 31 - 101\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
77.4 (+/- 11.6) 38 - 101\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.481\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Sex n (\%) Male Female\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
28 (38.9) 44 (61.1)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
28 (47.5) 31 (52.5)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
56 (42.7) 75 (57.3)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.324\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Nasal Pack n (\%) Unilateral Bilateral\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
55 (76.4) 17 (23.6)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
50 (84.7) 9 (15.30\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
105 (80.2) 26 (19.8)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.233\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
On Anticoagulant Yes No\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
38 (52.8) 34 (47.2)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
17 (28.8) 42 (71.2)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
55 (42) 76 (58)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.006\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Comorbidities n (\%) HTN AF CV disease Diabetes Mellitus CVA\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
30 (63.8) 27 (71.1) 20 (55.6) 4 (40) 10 (66.7)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
17 (36.2) 11 (28.9) 16 (44.4) 6 (60) 5 (33.3)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
47 38 36 10 15\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.127 0.018 0.933 0.322 0.333\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Clinical Variable\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Loop 1\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Loop 2\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Total\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
p-value\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Management n (\%) Inpatient Outpatient\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
72 (100) 0 (0)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
38 (64.4) 21 (35.6)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
110 (84) 21 (16)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Time to outpatient appt 1 day 2 days 3 days\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
14 (66.7) 5 (23.8) 2 (9.5)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Representation within 48 hours n (\%) Yes No\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0 72 (100\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
3 (5.1) 56 (94.9)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
3 (2.3) 128 (97.7)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Representation within 1 month n (\%) Yes No\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
11 (15.3) 61 (84.7)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
9 (15.3) 50 (84.7)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
20 (15.3) 111 (84.7)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.997\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Re-bled post pack removal n (\%) Yes No Unknown\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
5 (6.9) 65 (90.3) 2 (2.8)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
7 (11.9) 52 (88.1) 0 (0)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
12 (9.2) 117 (89.3) 2 (1.5\%)\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0.285\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Total length of inpatient stay (mean hours +/- SD) Range\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
45.7 (+/- 40.1) 12 -- 264\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
29.6 (+/- 29.8) 6 -- 144\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textless{}0.001\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Images}

Image 1\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Image 2\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Image 3\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Appendices}

\textbf{Appendix 1}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

